Patient Centered Medical Home Clinician Assessment Please answer the following questions based on the procedures and approaches used by you and your immediate care team (e.g. those nurses and office staff that you work with most closely on a daily basis) to take care of your patients. Do NOT answer this on the basis of your overall organization or even the entire clinic - but based on YOUR practice team. Circle the best answer. 1. My approach to improving the care of my patients with chronic disease can be characterized as I see these patients and provide the I try to keep track of my patients with I have implemented formal systems for services they need when they come to chronic diseases to monitor their care making sure that my patients with chronic see me in my office. between visits, but I haven t established disease are closely monitored, whether formal systems for doing this. they come in for office visits or not. 2. I use other staff members from my practice in my care of patients with chronic disease for such things as checking with patients on their adherence and response to treatment, patient education, patient self-management support, etc rarely, generally doing it all sometimes, with specific patients. routinely, with other staff members myself. having clearly defined roles as part of a care team for my patients with chronic disease. 3. A registry is a list of patients with a particular chronic disease or other condition that includes such things as patient name, contact information, date of last visit, and services that are due to be provided. Such a registry is not available in my practice, or is is available in my practice, and I use it is available in my practice, and I use it available but I don t use it. sometimes with my patients with a particular actively in tracking the care of most of my chronic disease. patients with chronic disease. 4. Reminders to clinicians of needed services for patients (either electronically or through some sort of paper tickler system) are not available in my practice, or are available, and I use them sometimes are used actively and regularly in the care are available but I don t use them in the care of my patients. of my patients by me and my care team. 5. I use flow sheets for my patients with chronic disease to provide a guide to management and to track critical elements of care.never sometimes, with selected patients routinely, with most or all patients
6. Feedback through performance measures regarding the care of my populations of patients with particular chronic diseases is not available, or is available but is provided and has some influence is routinely provided, and I use the I don t really use the information in the on how I practice. feedback to monitor my performance care of my patients. and make changes in how I provide care to my patients with chronic disease. Self-management support refers to a process in which a clinician actively engages patients in their own care, including having the patients set goals for various issues surrounding their care (such as targeted weight loss, activity levels, or disease outcomes such as Hgb A1c levels). This is particular useful for patients with chronic diseases, but also is appropriate for all patients, especially those needing to change health behaviors. 7. I assess the self-management needs and activities of my patients with chronic disease rarely. occasionally. routinely. 8. I provide self-management support for my patients rarely, or by distributing by distributing materials to help by distributing materials and providing educational materials (such as patients develop individualized self- counseling to help patients develop (pamphlets, or booklets) that do management plans, but without formal individualized self-management plans, and not include any specific self- follow-up on those plans with the having members of my care team follow up with management strategies. patients. the patients to reinforce their progress. 9. The information systems, registries, and/or patient records that I use in my care of patients with chronic disease do not include information include results of patient assessments include results of patient assessments, related to patient self-management (such as health behaviors and readiness to self-management goals developed jointly goals. engage in self-management activities), but with the patient, and reminders for the no specific patient self-management goals. clinician to periodically follow-up and re-evaluate the goals. 10. The care of my patients with chronic disease primarily relies on me, with centers on me, but with some help is a well-coordinated team effort few other resources involved. from other resources within my practice involving a number of different people and resources.
11. Setting specific patient-centered goals for health behavior change or for issues surrounding chronic diseases. is generally not done with my occurs sporadically with selected patients, is done collaboratively with most patients, patients, as I set the goals for their who are highly motivated and assertive. with specific goals that are systematically care and management. reassessed and progress documented on the patient s chart. 12. I use evidence-based guidelines for various chronic diseases. rarely or never to guide my patient care in general, but as the template for my care of my patients not in any formal way in my practice. with chronic disease, forming the basis for flow charts and systems used to monitor their care. 13. I share information with my patients regarding evidence based guidelines for their chronic disease. rarely or never. as part of patient education materials to assist patients and families in setting selfprovided to patients to help them understand management goals and tracking their own their care. care. 14. Consultation with specialists to help in taking care of my patients with chronic disease is accomplished by referral to specialists is accomplished by referral to some is coordinated with my care through who seldom communicate with me about specialists who communicate with me well through active and effective communication treatment plans and patient progress. and regularly and others who don t. with specialists in most areas of care. 15. Follow-up of my patients with chronic disease is largely left up to the patient is scheduled by the front desk in is assured by my care team, which contacts to return as necessary. accordance with guidelines that we the patient between visits to check on adherence have set up to the treatment plan, progress, side effects, etc. 16. I use flow sheets for my continuity patients to track their health maintenance and preventive care issues.never sometimes, with selected patients or routinely, with most or all patients and limited health maintenance issues. for most health maintenance issues.
17. Contact with my patients with chronic disease between office visits is done by me on an as-needed is done by me or by other care team is done on a planned basis by me or other basis with selected patients. members on a planned basis with trained care team members with most or all selected patients. patients with chronic disease, using a system with tracking and reminders. 18. I arrange for education for my patients with chronic disease (such as diet and other diabetic education for patients with diabetes) rarely, doing most of the for many of my patients with chronic for most or all of my patients with education myself. disease by referral to people in my practice chronic diseases through integrated. or the community who can provide most of the education service that coordinates with my education needed. care through active communication. 19. In order to improve the level of care available for my patients with chronic disease I have focused on my own practice I have sought out information regarding I have actively worked with community and not on community resources for community resources, but have not resources to impact the level of services patients with chronic disease. attempted to link with those resources. available for patients with chronic disease and to coordinate the care of my patients. 20. I use a symptom checklist with my depressed patients to monitor patient progress and change in the number or severity of depression symptoms.never sometimes, focusing on patients who routinely, to monitor treatment response do not seem to be improving. and to watch for relapse on stopping therapy. 21. Emotional health (such as symptoms of depression or anxiety, sources of stress, family conflicts) is not routinely assessed is assessed in my patients by is routinely assessed in my patients in my patients unless me when I see indicators that they are using standardized screening and monitoring they bring up problems. having problems. protocols.
22. Information about relevant subgroups of my patients with chronic disease needing services (such as those needing labs or referrals, not returning for follow-up, etc) is not available, or is available but can be obtained upon request, and is provided to me routinely and is used by I don t use the information. I occasionally use the information. me and my team to help deliver planned care to my patients with chronic disease. 23. In my delivery of preventive services to my patients, I rely on my patients coming have a system for tracking where have a system for tracking where in for health maintenance visits. my patients stand on preventive services my patients stand on preventive services that so I can remind them of what they need is used to send patients reminders regarding whenever they present for care. needed services. 24. When I receive feedback on my performance in the form of performance measurement data, I. pay little attention to use the data for myself to point share the data with the rest of my practice it. out areas that I need to work on, but as part of a process to identify and improve with no formal process for improvement. performance. 25. My level of participation in my practice s quality improvement process can be characterized as I work on things informally My practice has an improvement process I am an active part of our practice s to improve my care, but don t that operates sporadically, and I participate improvement process, which is very active have a formal process. in it at times. and meets regularly. 26. When my patients need counseling regarding health behavior changes (such as for diet, exercise, or stopping smoking), I provide limited counseling myself, provide limited counseling myself, plus provide extensive counseling myself based on with few or no other services available recommend at least some limited services goals set by the patients and/or refer them to to assist them. that are available in the community. specific services in my practice or community that are coordinated with my care.
27. When discussing treatment options with patients, I tell the patients my selection of the best outline other treatment options as well as carefully discuss the options and patient choice for them, mentioning other options my own selection to see if they have strong preferences, jointly coming to a consensus as I think necessary. feelings about the choice. regarding the best selection for the particular patient and situation. 28. My use of guidelines at the point of care to guide my decisions regarding the care of patients relies on my memory regarding the is supported by guideline-based reminders of is supported by automated reminder systems guidelines and what needs to be needed services for patients in a few key areas. based on guidelines for most chronic conditions accomplished for each patient. and preventive care areas and tailored to patients needs and self-management goals. 29. The care plans for my patients are basically outlined in my progress are summarized in a specific care plan are summarized in a care plan in the chart notes from patient visits. in the chart that is available to my staff. that includes patient goals and preferences for treatment and is used to guide the efforts of everyone involved with the patients care. 30. Effective mental health counseling for my patients with mental health issues is difficult to arrange, but I can is available by referral to mental health is readily available and is coordinated make a referral for patients who specialists who sometimes communicate with with my care through active and effective seriously need it. me regarding treatment plans and patient communication with the mental health progress. specialist. 31. The planning of care for my patients flows from my assessment of the is done by me, but with some discussion is done through interactive discussions and patient s needs. of the patient s specific needs and desires. goal setting with the patient and family by me and my care team. 32. In thinking about the composition of the team in my care of my patients
I view the team as consisting of I view the patient and family as part of the I actively engage the patient and family in health professionals only. team managing the patient s chronic illness. setting goals and managing the patient care plan. 33. In sharing clinical information with patients a paper copy of medication lists or lab/x-ray there is a system in place through which I make there is a web- based system for patients to reports is provided to the patient upon request. sure that patients are provided with their clinical access their clinical information and share their information, including lab/ray reports and medication personal health information with me or my staff. lists. 34. In order to enhance support for my patients with chronic disease I do not make use of peer support groups. I sometimes suggest that patients and families I routinely assist patients in connecting with find a peer support group. peer support groups in the community. 35. Considering our quality improvement processes in my practice I do not believe it is necessary to involve I believe that patients and families can help I actively engage patients in my practice s patients and families in our QI process. in enhancing my practice s QI process and quality improvement process. and occasionally ask for their input. Name of your practice: Your position in the practice (check the best response): Clinical faculty: Physician PA/NP Behavioral Other Non-clinical faculty First year resident Second year resident Third year resident Other How long have you worked in this practice? years and months. Copyright: Perry Dickinson, University of Colorado School of Medicine perry.dickinson@ucdenver.edu